North American Primary Care Research Research Articles

Guidance for researchers developing and conducting clinical trials in practice-based research networks (PBRNs).

There is increased interest nationally in multicenter clinical trials to answer questions about clinical effectiveness, comparative effectiveness, and safety in real-world community settings. Primary care practice-based research networks (PBRNs), comprising community- and/or academically affiliated practices committed to improving medical care for a range of health problems, offer ideal settings for these trials, especially pragmatic clinical trials. However, many researchers are not familiar with working with PBRNs. Experts in practice-based research identified solutions to challenges that researchers and PBRN personnel experience when collaborating on clinical trials in PBRNs. These were organized as frequently asked questions in a draft document presented at a 2013 Agency for Health care Research and Quality PBRN conference workshop, revised based on participant feedback, then shared with additional experts from the DARTNet Institute, Clinical Translational Science Award PBRN, and North American Primary Care Research Group PBRN workgroups for further input and modification. The "Toolkit for Developing and Conducting Multi-site Clinical Trials in Practice-Based Research Networks" offers guidance in the areas of recruiting and engaging practices, budgeting, project management, and communication, as well as templates and examples of tools important in developing and conducting clinical trials. Ensuring the successful development and conduct of clinical trials in PBRNs requires a highly collaborative approach between academic research and PBRN teams.

Health is primary: Family medicine for America's health.

More than a decade ago the American Academy of Family Physicians, American Academy of Family Physicians Foundation, American Board of Family Medicine, Association of Departments of Family Medicine, Association of Family Practice Residency Directors, North American Primary Care Research Group, and Society of Teachers of Family Medicine came together in the Future of Family Medicine (FFM) to launch a series of strategic efforts to "renew the specialty to meet the needs of people and society," some of which bore important fruit. Family Medicine for America's Health was launched in 2013 to revisit the role of family medicine in view of these changes and to position family medicine with new strategic and communication plans to create better health, better health care, and lower cost for patients and communities (the Triple Aim). Family Medicine for America's Health was preceded and guided by the development of a family physician role definition. A consulting group facilitated systematic strategic plan development over 9 months that included key informant interviews, formal stakeholder surveys, future scenario testing, a retreat for family medicine organizations and stakeholder representatives to review strategy options, further strategy refinement, and finally a formal strategic plan with draft tactics and design for an implementation plan. A second communications consulting group surveyed diverse stakeholders in coordination with strategic planning to develop a communication plan. The American College of Osteopathic Family Physicians joined the effort, and students, residents, and young physicians were included. The core strategies identified include working to ensure broad access to sustained, primary care relationships; accountability for increasing primary care value in terms of cost and quality; a commitment to helping reduce health care disparities; moving to comprehensive payment and away from fee-for-service; transformation of training; technology to support effective care; improving research underpinning primary care; and actively engaging patients, policy makers, and payers to develop an understanding of the value of primary care. The communications plan, called Health is Primary, will complement these strategies. Eight family medicine organizations have pledged nearly $20 million and committed representatives to a multiyear implementation team that will coordinate these plans in a much more systematic way than occurred with FFM. Family Medicine for America's Health is a new commitment by 8 family medicine organizations to strategically align work to improve practice models, payment, technology, workforce and education, and research to support the Triple Aim. It is also a humble invitation to patients and to clinical and policy partners to collaborate in making family medicine even more effective.

Infrastructure to support modern primary care: the NAPCRG debate update.

In December 2012, at the North American Primary Care Research Group (NAPCRG) conference in New Orleans (USA), associates of London Journal of Primary Care (LJPC) from London (UK) and Cleveland Ohio (USA) hosted a forum entitled ‘Local Health Communities for Integrated Care’. The forum was attended by senior practitioners/academics from different countries who debated the infrastructure needed to support collaboration at primary/community care level. They drew on lessons from West London's integrated care pilot1 and Cleveland's ‘Promoting Health across Boundaries’ initiative.2 Participants at the forum recognised international need for case studies of community-oriented integrated care (COIC), including primaryand community-care leadership of collaboration for integrated care, and continuous improvements of whole systems of care. In November 2013, at the NAPCRG conference in Ottawa (Canada), LJPC associates from Quebec (Canada) and London (UK) hosted a second forum to continue this conversation. In preparation for the Ottawa Forum, in October 2013 LJPC invited its readers to rank 11 aspects of integrated care in respect of their importance to research. Table 1 shows the results in order of most ‘votes’ overall (weighted formula). It also shows the first four (of 11) ‘votes’ of 61 respondents. Table 2 shows additional comments made by 30/61 respondents. Table 1 Priority aspects of integrated care to research Table 2 Additional comments made by 30 respondents about researching integrated care While ‘Patient Involvement’ and ‘Extended Multidisciplinary Primary Care Teams’ were perceived to be the most important aspects (and indeed 29/61 respondents gave them their first ‘vote’), the overall ranking pattern is more complicated. There is an argument for saying that all of these aspects are important, and their perceived importance may relate to their perceived neglect at present. Recognising the wide range of qualitative comments offered in Table 2, these initial results illustrate the range of research still needed to understand how the infrastructure of primary care can be developed, and, as discussions at the two conferences elaborated, more progress can be made in developing research that examines primary care in context.

Improvement of workflow and processes to ease and enrich meaningful use of health information technology.

The introduction of health information technology (HIT) can have unexpected and unintended patient safety and/or quality consequences. This highly desirable but complex intervention requires workflow changes in order to be effective. Workflow is often cited by providers as the number one ‘pain point’. Its redesign needs to be tailored to the organizational context, current workflow, HIT system being introduced, and the resources available. Primary care practices lack the required expertise and need external assistance. Unfortunately, the current methods of using esoteric charts or software are alien to health care workers and are, therefore, perceived to be barriers. Most importantly and ironically, these do not readily educate or enable staff to inculcate a common vision, ownership, and empowerment among all stakeholders. These attributes are necessary for creating highly reliable organizations. We present a tool that addresses US Accreditation Council for Graduate Medical (ACGME) competency requirements. Of the six competencies called for by the ACGME, the two that this tool particularly addresses are ‘system-based practice’ and ‘practice-based learning and continuing improvement’. This toolkit is founded on a systems engineering approach. It includes a motivational and orientation presentation, 128 magnetic pictorial and write-erase icons of 40 designs, dry-erase magnetic board, and five visual aids for reducing cognitive and emotive biases in staff. Pilot tests were carried out in practices in Western New York and Colorado, USA. In addition, the toolkit was presented at the 2011 North American Primary Care Research Group (NAPCRG) meeting and an Agency for Health Research and Quality (AHRQ) meeting in 2013 to solicit responses from attendees. It was also presented to the officers of the Office of the National Coordinator (ONC) for HIT. All qualitative feedback was extremely positive and enthusiastic. The respondents recommended that the toolkit be disseminated widely to improve staff education and training, leading to practice improvements.

NAPCRG 2012: reflections from across the pond

The 40th annual meeting of the North American Primary Care Research Group (NAPCRG) was held in New Orleans from 1–5 December 2012. As early-career family doctors from the UK we were keen to explore primary care research from around the world. With delegates from North America and Europe to the antipodes and Ethiopia, attending this conference far exceeded our expectations. The host city perfectly reflected the energy, diversity, and warmly receptive nature of the conference, which gave us a real feel for the enthusiasm to drive primary care forward in the US and Canada. We were impressed by the support shown by senior researchers to their junior colleagues, particularly during oral and poster presentations. The lack of pharmaceutical displays1 was welcome. The plenary sessions were inspirational. The opening plenary, ‘The Healing of America. A Global Quest for Better, Cheaper, and Fairer Health Care’ was given by former Washington Post journalist turned ‘healthcare expert’ TR Reid, who provided an engaging overview of healthcare systems around the world. It was fitting that he paid particular tribute to Lord Beveridge on the 70th anniversary of his landmark report. The design of a country’s healthcare system is a moral decision that requires clear commitment from the whole …

Publication of Research Presented at STFM and NAPCRG Conferences

Presentations of research are important in the dissemination of new knowledge, but they do not reach the same audience as research published in journals. The purpose of this study was to evaluate the proportion of presentations at recent major primary care research conferences that have become published. Oral and poster presentations for completed and work-in-progress projects from the 2007 and 2008 North American Primary Care Research Group (NAPCRG) and Society of Teachers of Family Medicine (STFM) annual conferences were included in the analysis. The first presenter for each presentation was searched on PubMed, and titles and abstracts for presentations were compared for content to titles and abstracts of potential matches found on PubMed. We analyzed the proportion of presentations that were published in peer-reviewed journals, mean time to publication, and the proportions of the type of journal in which the article appeared (family medicine vs other) were analyzed. There were 1,329 presentations included in the study. Overall, 34.4% of projects presented were also published. More oral presentations (42.9%) were published than were poster presentations (25.3%) (P <.001). Mean time to publication was 15.4 months. Oral presentations were published more quickly (13.7 months) than poster presentations (18.6 months) (P <.001). Published reports appeared in 192 different journals. Family medicine journals accounted for 36.5% of published. More than one-third of all presentations at STFM and NAPCRG conferences were published in journals indexed in PubMed. Time to publication was comparable to that of other specialties. Fewer than 2 of every 5 reports were published are in a family medicine journal, suggesting vast breadth in family medicine research. Family medicine academicians need to refocus efforts on transforming presentations into published articles in peer-reviewed journals for broader dissemination of research findings.

Essential requirements of information technology for primary care

Policy, economics and technology are driving primary care with unprecedented speed. Responding to this rapidly changing environment is essential for maintaining state-of-the-art care delivery. Although Health Information Technology (HIT) offers much promise to primary care, electronic health records (EHRs) have produced only modest improvements in quality. To understand how HIT could better meet the needs of primary care, the North American Primary Care Research Group (NAPCRG) gathered a select group of Family Medicine physicians from across North America and Europe with a broad range of informatics expertise. Over several months, the group discussed existing standards, classifications, modelling, communications, data structures, coding systems and how each of these enabled or hindered primary care delivery. During the discussions, a broad consensus emerged on HIT requirements essential to the primary care domain. This summary provides the author’s interpretation of the identified technical challenges in ontology, terminology, continuity and portability in terms more familiar to most Family Physicians. Although standardized EHR capabilities are described by Health Level Seven International [(www.hl7.org) a global standards development organization for health information], little is known about specific capabilities important to primary care. The committee characterized information services in terms of the capacity to support Family Medicine core values. Enhancement of continuing, comprehensive, compassionate and personal care provided an indication of responsiveness to primary care. The recommendations below reflect the most important challenges identified and provide a qualitative measure to discriminate HIT support for essential primary care services. The committee focussed on areas with known problems in order to guide providers, promote research and spur development by vendors.

Reply to Drs. Endersby et al

The Alma Ata and Astana Declarations reaffirm the importance of high-quality primary healthcare (PHC), yet the capacity to undertake PHC research—a core element of high-quality PHC—in low-income and middle-income countries (LMIC) is limited. Our aim is to explore the current risks or barriers to primary care research capacity building, identify the ongoing tensions that need to be resolved and offer some solutions, focusing on emerging contexts. This paper arose from a workshop held at the 2019 North American Primary Care Research Group Annual Meeting addressing research capacity building in LMICs. Five case studies (three from Africa, one from South-East Asia and one from South America) illustrate tensions and solutions to strengthening PHC research around the world. Research must be conducted in local contexts and be responsive to the needs of patients, populations and practitioners in the community. The case studies exemplify that research capacity can be strengthened at the <i>micro</i> (practice), <i>meso</i> (institutional) and <i>macro</i> (national policy and international collaboration) levels. Clinicians may lack coverage to enable research time; however, practice-based research is precisely the most relevant for PHC. Increasing research capacity requires local skills, training, investment in infrastructure, and support of local academics and PHC service providers to select, host and manage locally needed research, as well as to disseminate findings to impact local practice and policy. Reliance on funding from high-income countries may limit projects of higher priority in LMIC, and ‘brain drain’ may reduce available research support; however, we provide recommendations on how to deal with these tensions.

Family, Medicine, NAPCRG, and the Great Mandella

(Excerpts from acceptance of the Maurice Wood Award at the North American Primary Care Research Group Annual Meeting, Seattle, Washington, 2010.) In the mid 1970s, I remember NAPCRG as a small band of family physicians, none professing to be a researcher, but all believing that the future of

Editorial Board Updates

The Journal of the American Board of Family Medicine ( JABFM ) would like to take this opportunity to congratulate editorial board member Dr. Larry Culpepper, who accepted the Maurice Wood Award at the 2010 North American Primary Care Research Group's annual meeting. He joins Dr. Larry Green,

GENERATING THE KNOWLEDGE NEEDED TO MAKE THE PATIENT-CENTERED MEDICAL HOME A REALITY: A COLLABORATIVE PROJECT OF THE PRIMARY CARE SPECIALTIES

GENERATING THE KNOWLEDGE NEEDED TO MAKE THE PATIENT-CENTERED MEDICAL HOME A REALITY: A COLLABORATIVE PROJECT OF THE PRIMARY CARE SPECIALTIES

MORE BELLS AND WHISTLES: INTRODUCING THE RECENTLY REVAMPED NAPCRG WEB SITE

The North American Primary Care Research Group (NAPCRG) is pleased to offer an enhanced Web site (<http://www.napcrg.org>) that is easy to navigate and packed with worthwhile information. The revamped Web site now includes pertinent information about NAPCRG as an organization, member services,

Health literacy: setting an international collaborative research agenda

BackgroundHealth literacy is an increasingly important topic in both the policy and research agendas of many countries. During the recent 36th Annual Meeting of the North American Primary Care Research Group, the authors led an audio-taped 3-hour forum, "Studying Health Literacy: Developing an International Collaboration," where the current state of health literacy (HL) in the United States (US) and United Kingdom (UK) was presented and attendees were encouraged to debate a future research agenda.Discussion of Forum ThemesThe debate centred around three distinct themes, including: (1) refining HL definitions and conceptual models, (2) HL measurement and assessment tools, and (3) developing a collaborative international research agenda. The attendees agreed that future research should be theoretically grounded and conceptual models employed in studies should be explicit to allow for international comparisons to be drawn.Summary and Authors ReflectionsThe importance of HL research and its possible contribution to health disparities is becoming increasingly recognised internationally. International collaborations and comparative studies could illuminate some of the possible determinants of disparities, and also possibly provide a vehicle to examine other research questions of interest.

NAPCRG Congratulates AAFP National Research Network on its 10th Anniversary

The North American Primary Care Research Group congratulates the American Academy of Family Physicians National Research Network (AAFP NRN) in celebrating its 10-year anniversary in November 2009. The AAFP NRN has received generous support from the AAFP since its inception and provides varied

FAMILY MEDICINE RESIDENT AWARD FOR SCHOLARSHIP

The need for capacity building in family medicine research is well recognized. One strategy for accomplishing this goal is to mentor and recognize residents for their accomplishments in scholarly activities. The Association of Family Medicine Residency Directors (AFMRD), the North American Primary Care Research Group (NAPCRG), and the College of Family Physicians of Canada (CFPC) have developed the AFMRD / NAPCRG / CFPC Family Medicine Resident Award for Scholarship to both recognize resident scholarly activity and, by doing so, promote increased capacity building in family medicine research and scholarly activity. One award will be made by each family medicine residency program annually. The AFMRD / NAP-CRG / CFPC Boards have suggested that each program create a committee to review resident scholarly activity applications and make the award recommendation to the program director. AFMRD / NAPCRG / CFPC does not select the honorees; departments or programs will inform the organizations who should be honored from their program. AFMRD / NAPCRG / CFPC supply the certificate that will be presented to the resident receiving the award to the program. As developed by the participating organizations, the following restrictions apply: No resident may win the award more than once, only one award per program will be awarded annually, the scholarly activity for consideration must have been completed while the resident was in residency training, the nature of the scholarly activity and whether it “qualifies” is at the discretion of the program’s award committee, jointly-done scholarly activity between 2 or more residents may be eligible for a joint award (each resident will receive a certificate), and scholarly activity must be in large measure performed by the resident—this activity includes most, but not necessarily all, of the following: the inception of the idea, development of the project, gathering data, presenting the results, or writing a report or publication. The AFMRD / NAPCRG / CFPC Family Medicine Resident Award for Scholarship was first available last year to residency programs. Further information regarding deadlines for submission of nominees will be provided to program directors later this year.

DEFINITIONS OF COMMON TERMS RELEVANT TO PRIMARY CARE RESEARCH

The following definitions of terms commonly used by primary care researchers were developed by the Practice-Based Research Subcommittee of the North American Primary Care Research Group (NAPCRG) Committee on Advancing the Science of Family Medicine(CASFM) after reviewing available definitions,

North American Primary Care Research Group President's Award

Dr. Puffer and the American Board of Family Medicine Receive the North American Primary Care Research Group President's Award At the October 2007 annual meeting of the North American Primary Care Research Group (NAPCRG) in Vancouver, British Columbia, Canada, the NAPCRG President's Award was

Family Practice and the new era of electronic publishing

It is now nearly two years since I became editor of Family Practice. In that time there have been many changes to the journal, with the introduction of electronic submissions, e-letters, online-first publication of PDFs and a new journal website. Family Practice is unique as the only ‘international’ primary care research journal, and we have taken steps to consolidate the journal in that role. The editorial board has recently expanded to include more members from North America and Southern Europe, as well as adding more capacity in both qualitative research and epidemiological methods. I am indebted to our existing associate editors, Professor Paul Little (Southampton, UK) and Professor Tom Fahey (Dublin, Eire), who assist in decisions, as well as Professor Martin Dawes (Montreal, Canada), who edits the website and e-letters, and Professor Lorne Becker (Florida, USA), who edits reviews. I am also delighted to announce that Professor Doris Young (Melbourne, Australia) will join the editorial team. One of the hazards of the journal’s growth has been an increase in submissions from 300 per year to more than 500, which has led to some delays in editorial turnaround, extending our mean from 66 days to 84. In response to this we will be recruiting three more associate editors to bring our first-decision time back to our target of 56 days (see the advert in this issue of the journal). Family Practice is edited by a team of active primary care researchers who are involved in leading research teams themselves as well as contributing to the journal. Our intention is to make this the world’s leading primary care research journal by attracting the best authors with the most to say to a worldwide audience. Family Practice publishes around 120 original articles a year, with the principal criteria for acceptance being scientific validity and international relevance. I am pleased to announce that our ISI Impact Factor for 2002–2003 rose 30% from the previous year to 1.3. Some 70% of articles published in Family Practice come from outside the UK, and we record in excess of 25,000 downloaded articles per year from Highwire. I would like to thank the editorial board, authors, reviewers and all those who contribute to the success of the journal. We continue to link with important organisations for primary care research and to offer a 70% discount to individual subscribers who are members of these organisations, including WONCA, the European General Practice Research Network, the Society for Academic Primary Care (UK) and the North American Primary Care Research Group. We receive many articles reporting otherwise worthy research that fails to consider the international dimension. This is a challenge to which researchers must rise. Even research rooted in addressing an issue of importance to a national health care system, for example access to out-of-hours care, can be designed and written up in such a way that it can inform practice in other countries. Aside from clinical issues, health systems in many countries face similar challenges over access and affordability of care, adoption of new technologies, patient safety and professional development. It is our intention that Family Practice continue to be in the forefront of informing these debates. Articles in this issue consider a wide range of topical issues from basic epidemiology to studies of patient’s views and experiences. This continues the journal’s now 22-year history of publishing a wide range of original research that will impact on patient care worldwide. During the coming year readers will see a continuation of our steps to keep abreast of developments in publishing. The website continues to be the place where articles are published ‘first’, obtaining their DOI number and date of publication for Medline about three months before appearing in the print journal. In order to publish more articles in print we are shifting entirely to electronic correspondence, and I would remind you to use the e-letters facility alongside the electronic version of articles in Highwire if you wish to comment on an article. We will also be publishing regular news and links to conferences and the like on the website. Family Practice is predominantly an electronic journal, if you consider that our downloads exceed our paper footprint by a factor of 100 or so. Many thousands obtain access to Family Practice via institutional subscriptions, and in developing countries this access is free. In addition, all articles published in Family Practice are open access after a year, and from

NAPCRG ACTION PLAN FOR THE FUTURE OF FAMILY MEDICINE

The North American Primary Care Research Group (NAPCRG) has been an active partner in the Future of Family Medicine (FFM) project and is committed to moving the FFM recommendations forward. To this end, NAPCRG has created a task force to develop strategies and provide oversight for accomplishing its work of the NAPCRG FFM action plan. This brief report summarizes the work of the task force to date and sets out the work plan for the task force and NAPCRG.

Frequently Asked Questions About Family Medicine Research for Medical Students and Residents

The Future of Family Medicine report emphasizes the importance of research to all family physicians and the need to expose students and residents to research experiences in family medicine. The North American Primary Care Research Group (NAPCRG) is pleased to offer the following Frequently Asked